Home Care Policies and Procedures Manual: What Must Be Included
The required policy categories, accreditor breakdowns, and update rules every home care agency needs to build a survey-ready P&P manual.
Published May 26, 2026 · 8 min read · By Cal Nesvig, Founding Partner, AveeCare
Key Takeaways
- P&P manual covers five categories: clinical, admin, safety, emergency, compliance.
- Medicare-certified agencies must meet CMS 42 CFR Part 484.
- ACHC and CHAP are CMS-deemed; accreditation replaces the Medicare survey.
- Review policies annually; update within 30 days of any change.
- Deficiencies almost always trace to a missing or outdated policy.
How to use this scorecard
Check each policy your agency has documented. The scorecard scores your completeness against CMS 42 CFR Part 484 and ACHC/CHAP accreditation standards.
AveeCare stores, versions, and enforces your P&P manual at $6 per active client per month. See how agencies stay survey-ready.
See how it worksWhat is a home care policies and procedures manual?
A home care P&P manual is the agency's official written record of how every clinical and operational process must be carried out.
P&P manual vs. employee handbook
A P&P manual governs how care is delivered. An employee handbook governs employment terms. They are separate required documents with different regulatory functions.
CMS 42 CFR Part 484 establishes the regulatory floor for Medicare-certified home health agencies. CMS surveyors evaluate compliance against the State Operations Manual Appendix B, the actual checklist surveyors carry during inspections.
| P&P Manual | Employee Handbook | |
|---|---|---|
| Regulatory driver | CMS 42 CFR Part 484, state licensure | FLSA, state employment law |
| What it covers | Clinical and operational processes | Employment terms, conduct, PTO |
| Who maintains it | QA director or administrator | HR director or owner |
Non-medical personal care agencies that do not seek Medicare certification still need written P&Ps for state licensure. Required categories overlap substantially with the Medicare CoP framework: client intake, service agreements, incident reporting, and emergency procedures are near-universal. For employment-term policies (conduct, PTO, at-will), see the employee handbook vs. P&P manual guide.
What policy categories must a home care agency have?
Home care agencies need policies in five categories: clinical care, operations, infection control, emergency preparedness, and compliance.
| Category | Key Policies Required | Primary Regulatory Driver |
|---|---|---|
| Clinical Care | Assessment, care planning, medication management, fall prevention | 42 CFR 484.60, 484.65 |
| Administrative / Ops | Client intake, service agreements, billing, clinical records | 42 CFR 484.50, 484.110 |
| Infection Control | Standard precautions, PPE, exposure response, cleaning | 42 CFR 484.70, OSHA, CDC/NIOSH |
| Emergency Preparedness | Disaster plan, evacuation, continuity of care | 42 CFR 484.102 |
| Compliance / Billing | HIPAA, fraud and abuse prevention, documentation standards | HIPAA, HHS OIG, 42 CFR 484.110 |
Assessment protocols, individualized care plans, medication administration, and fall prevention procedures.
Client intake, service agreements, billing procedures, and clinical records management.
Standard precautions, PPE requirements, exposure response, and environmental cleaning protocols.
Disaster response plan, evacuation procedures, and continuity-of-care protocols with documented annual exercise.
Caregiver competency evaluation, supervision requirements, background check policy, and training documentation.
HIPAA privacy, fraud and abuse prevention, documentation standards, and audit response procedures.
State licensing adds to the federal floor
Your state may require additional policies beyond CMS minimums. Verify with your state health department before submitting your licensure or accreditation application. See state licensing requirements by state.
Non-medical personal care agencies face lighter but still real P&P requirements at the state level. The categories overlap substantially with Medicare CoP requirements: client intake, caregiver conduct, incident reporting, and emergency procedures are required in nearly every state. Clinical policies must also align with documentation requirements for home care agencies.
What does each accreditor require for home care policies?
ACHC, CHAP, and the Joint Commission each add policy requirements beyond the CMS baseline; ACHC and CHAP are CMS-deemed and substitute for a Medicare survey.
| Accreditor | CMS-Deemed? | Notable Additional P&P Requirements | Best For |
|---|---|---|---|
| ACHC | Yes | Quality improvement program, infection prevention committee, patient rights documentation | Agencies seeking streamlined CMS deeming |
| CHAP | Yes | Community health integration policy, staff competency verification program | Mission-driven or faith-affiliated agencies |
| Joint Commission | Yes | Tracer methodology compliance, sentinel event policy, performance improvement plan | Hospital referral-preferred agencies |
Accreditation replaces the CMS certification survey
Earning ACHC or CHAP accreditation substitutes for a Medicare certification survey. Budget 6 to 12 months and submit your full P&P manual with the application.
The Joint Commission's home care accreditation is the least common of the three but carries the strongest brand recognition with hospital discharge planners, making it valuable for agencies that depend on hospital referral pipelines.
How should a home care P&P manual be structured?
Organize your manual by category, number every policy with a version date and approver signature, and build a formal annual review calendar.
Assign a QA director or administrator as the official policy owner. This person is responsible for review scheduling, version tracking, and surveyor-readiness at all times.
Use a category prefix plus policy number plus version (e.g., CC-001-v3 for Clinical Care policy 1, version 3). This makes retrieval and version control auditable.
List every policy by category with its policy number, effective date, and last review date. Surveyors often request the TOC first to scope their pull list.
Set annual review dates for every policy plus event-triggered reviews after regulatory changes, deficiency notices, or serious incidents. Put calendar reminders in your scheduling system.
Record the date, a brief change summary, and the approver's initials for every policy update. This revision log is what CMS surveyors check to confirm ongoing governance.
No revision date is a survey red flag
CMS surveyors check dated signatures and documented review history on every policy they pull. A policy with no revision date is treated as never reviewed.
How often should home care policies and procedures be reviewed?
Every policy requires an annual review at minimum, plus a triggered review within 30 days of any regulatory change, deficiency notice, or serious incident.
The QA director or designated policy owner should sign off on each reviewed policy. Version history, including the original effective date, every subsequent review date, and approver initials, must be logged either in the manual itself or in a policy management system.
Stale policies trigger deficiency notices
A policy last reviewed in 2021 or earlier is a survey deficiency risk. CMS requires documented evidence of ongoing review, not just a cover-page date.
Which survey deficiencies trace back to missing policies?
The most cited survey deficiencies, from infection control lapses to missing care plans, each trace back to a specific missing or outdated policy.
| Survey Deficiency | CMS CoP Tag | Policy to Add or Strengthen |
|---|---|---|
| Infection control breach | 484.70 | Infection prevention and control policy with standard precautions and PPE. See infection control policies for caregivers. |
| Care plan not individualized | 484.60 | Care planning and assessment policy with documented update triggers |
| Emergency plan not exercised | 484.102 | Emergency preparedness policy with annual exercise documentation requirement |
| Staff competency not verified | 484.115 | Caregiver competency evaluation and ongoing supervision policy |
After receiving a deficiency notice, the agency must submit a Plan of Correction within 10 days. The plan must identify the root policy gap, the corrective action, who is responsible, and the target completion date. AveeCare's compliance module logs corrective actions and tracks policy revision status in real time.
Run a pre-survey compliance audit
Before any scheduled survey, audit your P&P manual against the deficiency list above. Our home care compliance audit guide walks through the full pre-survey checklist.
Frequently Asked Questions
Sources
- 1.CMS 42 CFR Part 484, Home Health Conditions of Participation
- 2.CMS State Operations Manual Appendix B, Interpretive Guidelines for Home Health
- 3.Medicare and Medicaid Programs, Conditions of Participation for Home Health Agencies, Final Rule (Federal Register, January 13, 2017)
- 4.ACHC Home Health Accreditation Standards
- 5.CHAP Home Health Accreditation Standards Overview
- 6.OSHA Home Healthcare Worker Guidelines
- 7.CDC/NIOSH Health and Safety Topics, Home Healthcare
- 8.HHS Office of Inspector General, Compliance Program Guidance